Awareness of obstetric fistula and its associated factors among reproductive-aged women: Demographic and health survey data from Gambia

Childbirth complications continue to remain a major problem in various settings but most rampant in underdeveloped nations, including Gambia, where poor living condition is widespread. Obstetric Fistula (OF) has been cited as one of the most common issues experienced by mothers during labor over the years. The study thus focuses on evaluating the level of awareness of this condition among Gambian women of childbearing age. Women’s Data from the recent Demographic and Health Survey (DHS) in Gambia was used for the study. A total of 11,864 women of reproductive age, who had completed cases of the variables of interest were used for the analysis. Stata version-16 was used in carrying out the analysis of this study; and Pearson Chi-square test for independence was used to examine the distribution of the awareness of fistula among Gambian women across the explanatory variables. A two model binary logistic regression was fitted to examine the association between the outcome variable and the explanatory variables. The study presented that, majority of the Gambian women (87.2%) had no knowledge about Obstetric Fistula, as they indicated to have never heard of the condition. Considering the individual factors, age was seen to be a significant factor in determining the awareness level of Obstetric Fistula among women of childbearing age. As they age, the higher their odds of knowing about the condition. Other factors such as level of education, marital status, pregnancy termination, media exposure, community poverty level, and employment were also discovered to be significant factors in determining a woman’s awareness of Obstetric Fistula. Considering the low level of awareness of Obstetric Fistula among Gambian women, there is therefore the need for the appropriate institutions to increase health educational programmes targeted at creating its awareness, and to provide further in-depth understanding of the condition to the few who already have a fair knowledge about it.


Introduction
Childbirth complications continue to remain a major problem in various settings but most rampant in underdeveloped nations, including Gambia, where poor living condition is widespread. Obstetric Fistula (OF) has been cited as one of the most common issues experienced by mothers during labor over the years. The study thus focuses on evaluating the level of awareness of this condition among Gambian women of childbearing age. Methods Women's Data from the recent Demographic and Health Survey (DHS) in Gambia was used for the study. A total of 11,864 women of reproductive age, who had completed cases of the variables of interest were used for the analysis. Stata version-16 was used in carrying out the analysis of this study; and Pearson Chi-square test for independence was used to examine the distribution of the awareness of fistula among Gambian women across the explanatory variables. A two model binary logistic regression was fitted to examine the association between the outcome variable and the explanatory variables.

Results
The study presented that, majority of the Gambian women (87.2%) had no knowledge about Obstetric Fistula, as they indicated to have never heard of the condition. Considering the individual factors, age was seen to be a significant factor in determining the awareness level of Obstetric Fistula among women of childbearing age. As they age, the higher their odds of knowing about the condition. Other factors such as level of education, marital status, pregnancy termination, media exposure, community poverty level, and employment were also discovered to be significant factors in determining a woman's awareness of Obstetric Fistula. Conclusion Considering the low awareness level of Obstetric Fistula among Gambian women, there is therefore the need for the appropriate institutions to increase health educational programmes targeted at creating its awareness, and to provide further indepth understanding of the condition to the few who already have a fair knowledge about it.

Introduction
Childbirth complications continue to remain a major problem in various settings but most rampant in underdeveloped nations, including Gambia, where poor living condition is widespread. Obstetric Fistula (OF) has been cited as one of the most common issues experienced by mothers during labor over the years. The study thus focuses on evaluating the level of awareness of this condition among Gambian women of childbearing age.

Methods
Women's Data from the recent Demographic and Health Survey (DHS) in Gambia was used for the study. A total of 11,864 women of reproductive age, who had completed cases of the variables of interest were used for the analysis. Stata version-16 was used in carrying out the analysis of this study; and Pearson Chi-square test for independence was used to examine the distribution of the awareness of fistula among Gambian women across the explanatory variables. A two model binary logistic regression was fitted to examine the association between the outcome variable and the explanatory variables.

Results
The study presented that, majority of the Gambian women (87.2%) had no knowledge about Obstetric Fistula, as they indicated to have never heard of the condition. Considering the individual factors, age was seen to be a significant factor in determining the awareness level of Obstetric Fistula among women of childbearing age. As they age, the higher their odds of

Introduction
Obstetric fistula is one of the most devastating and catastrophic childbirth injuries. It is characterized by a hole which occurs between the birth canal and the bladder, where the rectum is sometimes included as well. This is caused by delayed, complicated labour without access to early, high-quality medical attention. It causes women and girls to leak fluids (i.e. faeces, urine) or both, and frequently leads to persistent medical issues, hopelessness, social isolation, and hardship (1). Fistula affects an estimated half a million women and girls in Sub-Saharan Africa, Asia, the Arab States area, and Latin America and the Caribbean, with new instances emerging every year. Yet fistula is pretty much fully controllable (1,2).
Its recurrence is a clear indication of vast discrepancies, a symptom of global inequality, and proof that health and wellbeing institutions are failing to safeguard the administration of human rights of the economically marginalized women and girls. Precise obstetric fistula prevalence numbers (globally and nationally) are unknown owing to faulty reporting, under reporting, and embarrassment, which prevents women from making complaints about fistula. However, an estimated 50,000 to 100,000 women suffer fistula each year, with around 2 million women already living with the condition, which is a burden in nearly 60 nations (3).
Based on data from two African countries, including The Gambia, the most recent communitybased prevalence estimate is 160 (95 percent CI 116-210) obstetric fistulas per 1000 women of reproductive age (4).There are several nations in South Asia, notably Bangladesh, and in sub-Saharan Africa, such as Sudan, Ethiopia, Chad, Ghana, and Nigeria, where fistula incidence is estimated to be prominent (5). 5 A variety of studies have discovered that women's educational level, age, history of pregnancy, distance to the nearest health facility, and awareness of obstetrics problems are the primary elements linked with women's awareness of obstetrics fistula (3,6). While prolonged labour and a lack of timely accessibility to emergency obstetric treatment are the most common leading antecedents of obstetric fistula in underdeveloped countries, widespread poverty is frequently a fundamental factor. According to studies, fistula sufferers tend to reside in rural places and are more disadvantaged (7,8).
Given the negative implications of fistula on the health of women and girls, management and rehabilitation are major public health problems. It is projected that if all affected women received treatment, given the current pace of surgical therapy of fistulas, it will take nearly 55 years to repair all existing sufferers, let alone tackle the new cases that develop each year (9).
Surgical intervention to correct the fistula is followed by therapy, which involves extending and moving limbs that have ceased to function as a result of genital tract and sciatica nerve injury. Lower limb paralysis, foot drop, and limb contracture require physiotherapy to be treated (10). Psychological and emotional therapy, skill improvement, and outreach to identify women with perforations and transfer them to distant treatment clinics help solidify treatment activities (11). Although fistula repairs have a success rate of up to 90%, many women are unaware that treatment for their illness is actually available (5,12) and a greater number of women are not even aware of the obstetric fistula condition. In response, Gambia launched a 2017-2021 project with the goal of funding at least 150 fistula repair procedures in The Gambia (13). As of 2021, Gambia, in collaboration with other institutions, were able to support 19 repair procedures, giving hope to women suffering from this illness. It is 6 undeniable that the first step in resolving any health issue is being aware of its existence and identifying it. However, there is a paucity of evidence on the awareness of women in Gambia on OF. The study therefore aims at investigating the awareness of obstetric fistula and its associated factors among Gambian women of reproductive age.

Data source
Data from the recent Demographic and Health Survey (DHS) in Gambia was used for the study.
Specifically, the study used the women's recode file also known as the Individual Recode (IR).
DHS is a comparable nationally representative survey undertaken regularly in over 90 countries, enhancing global understanding of developing country health and demographic trends (14). The DHS Program's major goal is to improve demographic, health, and nutrition data collection, analysis, and distribution, as well as to make these data more useful for planning, policymaking, and program management (14).

Study design and sampling procedure
A descriptive cross-sectional design was employed for the survey. Validated and pretested structured questionnaires were used to collect data from the respondents on health and social issues such as maternal health service utilization and women empowerment and sociodemographic characteristics (14,15). The survey was conducted using a two-stage cluster sampling technique. To begin, a stratified sample of enumeration areas (EAs) is chosen using probability proportional to size (PPS): a sample of a preset number of EAs is chosen independently in each stratum using probability proportional to the EA's measure of size. A listing technique is used in the designated EAs to ensure that all dwellings/households are listed. Second, households in the selected EAs are selected using equal probability systematic sampling. A detailed procedure for sampling has been described elsewhere (16). We included 11,864 women with complete cases of variables of interest in the study. We also adopted the 8

STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines
in drafting this manuscript (17). The dataset is freely available to download at https://dhsprogram.com/methodology/survey/survey-display-555.cfm.

Outcome variable
The outcome variable of this study was women's awareness of obstetric fistula. The variable measures the extent to which women are aware of obstetric fistula. This variable was derived from the question "have you heard about fistula?" Responses to this question was categorised into "no" and "yes". The variable was dichotomised into 1= "ever heard of fistula" and 0= "never heard of fistula". Studies that used the DHS dataset employed similar coding (2,18,19).

Explanatory variables
The explanatory variables considered in this study were selected based on their association with awareness of fistula from literature (2,18,19) and also their availability in the DHS dataset.
A total of seventeen (17) variables were included in the study. These variables can be grouped as individual and contextual factors. The individual factors considered were mother's age, educational level, marital status, religion, employment status, parity, wealth index, frequency of reading newspaper, frequency of listening to radio, frequency of watching television, sexual activity, pregnancy status and pregnancy termination. The contextual factors included were type of place of residence, region, community literacy level and community poverty level. The categories of each of the variables are shown in Table 2.

Statistical analyses
Stata version 16.0 was used to carry out the analysis in four steps. At the first stage, a graphical chart was used to summarize the results of the proportion of awareness of fistula among women in Gambia. The Pearson chi-square test of independence was adopted to examine the distribution of the awareness of fistula among women across the explanatory variables. A multi-collinearity test using the variance inflation factor (VIF) was conducted to examine the collinearity among the variables. The results indicated that the minimum, maximum, and mean VIFs were 1.04, 6.70, and 2.26 respectively; hence, there was no evidence of collinearity among the variables included in the regression analysis. Finally, a two model binary logistic regression was fitted to examine the association between the outcome variable and the explanatory variables. In the first model (Model I), there was a bivariate binary logistic regression where each of the independent variables was fitted. In the second model, Model II, which is the complete model, a multivariate binary logistic regression was fitted. Odds Ratio of 95 percent confidence intervals (95% CIs) was used to present the findings of the regression analysis. To account for disproportionate sampling and non-response, the "svyset" command was used, and weighting was done to account for the intricate nature of DHS data.

Ethical Approval
The survey reported that ethical approval was granted by the Institutional Review Board of ICF International and Ethical Review Committee of Gambia Health Service (20). We further obtained permission from the DHS Program for use of this data for the study. The data can be accessed from their website (www.measuredhs.com ). Women who read newspaper, listened to radio and watched TV for at least once a week had the highest proportion of fistula awareness (20.2%, 14.9% and 14%) respectively. About two in ten (17.1%) of women with the highest wealth index were aware of fistula. Highly educated women had the highest proportion of fistula awareness (28.5%). Only 8.4% of women who had never had sex were aware of fistula whilst women who have had sex before reported 14.6% fistula awareness. Fewer women (12.7%) who are not pregnant were aware of fistula while 14.5% pregnant women were aware of fistula. Also, women who had terminated pregnancy before had a higher fistula awareness (17.6%) whereas women who had never terminated pregnancy before had a lower fistula awareness (11.9%).

Prevalence of Fistula awareness among women in Gambia
In terms of sub region, women in Juntaur recorded the highest proportion of fistula awareness (16.6%) whereas women in Janjanbureh had the least fistula awareness (7.7%).
Regarding community literacy and poverty level, women in high literacy and high poverty communities had the greatest fistula awareness (14.3% and 15%) respectively. The chi-square test analysis indicated statistically substantial association between all the explanatory variables and fistula awareness except currently pregnant and type of place of residence (see ,   Table 1).

[Insert table 1]
The outcome of the Binary Logistic Regression has been presented in Table 2 Women that listen to radio and read newspapers at least once a week had higher odds of fistula awareness than women that do not listen to radio or read newspapers (respectively; AOR= 1.40, CI=1.23-2.83 & AOR=2.15, CI=1.64-2.83). After adjusting for the covariates, women who listen to radio at least once a week and read newspapers less than once a week had a higher odds of fistula awareness than women who do not listen to radio or read newspapers.

Discussion
Mitigating obstetric fistula (OF) is critical to the attainment of SDG target 3.1. The study looked at the level of awareness obstetric fistula and the factors that influence it in Gambian women of reproductive age. Overall, the prevalence of OBF awareness in Gambia was 12.9%. This result 14 was much lower than studies in Nigeria and Tanzania (57.8% and 60.1%) (21,22) respectively. A plausible justification for this finding can be attributed to the differences in study period, design, and sample size. Nevertheless, the finding suggest that fistula awareness is very low in Gambia. This may have a detrimental effect on African countries' quest to mitigate obstetric fistula as women in Gambia are more likely to stay home rather than seek medical intervention (23).
According to the findings, age, marital status, employment position, media exposure, and educational level were all significant socio-demographic factors associated with fistula awareness. The likelihood of being aware of fistula increases with age (e.g. women in 45-49 age bracket were twice likely to be aware of fistula compared to those in [15][16][17][18][19]. That is, older women are more likely to be aware of fistula than younger women. This result is in line with prior research from Ethiopia (24) and Uganda (25). The fundamental assumption behind this assertion is that, the older a woman gets, the more experience she would have with birth and its concomitant complications. Our study also revealed that unmarried women in Gambia are less likely to be aware of fistula compared to married women. This is largely due to the influence of the husbands of the married women. Married women, due to the influence of their partners are more likely to seek healthcare services such as obstetric counselling which creates an avenue of increasing awareness among them. There is also the possibility of knowledge transfer from husband to wife. The decision making power of a Gambian woman to visit health institution during labour is very low, the authority is largely made by their husbands (26). 15 Compared to women who were not exposed to mass media (i.e. reading newspapers and listening to radio), women who were exposed to mass media were more likely to be aware of obstetric fistula. The findings of prior investigations in Nigeria (18) and Ethiopia (27) complement the findings of this study. The finding is probably due to the fact that the media is a vital conduit for conveying information, such as information regarding OF, its signs and symptoms, and information about where to get treatment. As enshrined in (6), most women who are aware of fistula got the information from the media.
Higher level of education among women of reproductive age directly translate to higher health literacy. Education level is a significant predictor of women's awareness of fistula in Gambia. It has been established in several studies (28) that education gradient positively associate with better health behaviours (such as seeking obstetric counselling) and improved health status (fistula awareness). Several other studies (6,29,30) had similar findings that women with higher education are more likely to have improved health status (aware of fistula) compared to those without formal education. Formal education empowers women to make better healthcare decision such as attending health education forums and alter habits that are detrimental to ones' health.
As expected, there is a strong association between fistula awareness and pregnancy termination. Women who had history or were exposed to pregnancy termination were 1.21 times more likely to have better awareness of fistula than those who had not. The finding could be rationalized by the fact that pursuing healthcare services such as pregnancy termination services presents an avenue for women to be exposed to health education and 16 promoting messages, perhaps raising their awareness of fistula. Similar finding was reported by Aleminew et al. (23) and Asefa et al. (27).
Compared to Banjul, which is a major urban concentration in Gambia, women in these rural towns (Juntaur and Mansakonko) are 1.92 and 1.60 times more likely to be aware of fistula.
The high prevalence of obstetric fistula in rural areas in Gambia (31) could explain why awareness of fistula is high also in these towns. However, the finding deviates from the findings of several similar studies which posits that awareness is rather high in urban areas (6,26).

Strength and weakness
By far, our literature review shows that this is the first study to use nationally representative datasets from Gambia to investigate the prevalence of and factors associated with obstetric fistula awareness. This is a significant addition to the existing literature. However, there are some downsides to consider. The DHS does not break down the question to assess which type of fistula women are aware of (e.g., vesicovaginal fistula, urethrovaginal fistula, or rectovaginal fistula). In the future, this disaggregation could be considered for the DHS dataset. Also, the cross-sectional study design does not allow us draw direct causal inference to the factors associated with obstetric fistula awareness.

Conclusion
The present study sought to assess the magnitude and factors associated with fistula awareness in Gambia. We conclude that obstetric fistula awareness is very low in Gambia. As such, immediate remediating action is needed to raise women's awareness about OF. It is 17 evident from the study that age, level of education, marital status, pregnancy termination, media exposure, community poverty level, and employment status were significant factors associated with OF awareness. To raise women's awareness of fistula, there is the need for public health interventions to consciously raise community literacy rate, increase access to mass media platforms and invest intensively in formal education for women.